Diagnosis of pregnancy &antenatal care for undergraduate

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Udergraduate course lectuers in OB&GYNE,Faculty of medicine ,Zagazig University

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  • to detect problems that might affect the woman's pregnancy and require additional care - routinely screen for anemia, hypertension, HIV, syphilis and diabetes mellitus. Recognize other problems that may complicate pregnancy: malnutrition and tuberculosis, vaginal bleeding, vaginal discharge, fetal distress and abnormal fetal position after 36 weeks Danger and emergency signs: Fever, vaginal bleeding, headache and blurring of vision, severe abdominal pain, convulsion, severe difficulty of breathing Birth and emergency plan
  • The World Health Organization (WHO) recommends giving ferrous sulfate 320 milligrams (60 mg of elemental iron) twice a day to all pregnant women. If the woman’s hemoglobin is 8 gm or less at any visit, increase her iron supplementation to three times a day for the entire pregnancy. If ferrous sulfate is not available, give an equal amount of elemental iron in another iron preparation.
  • Distinguish chronic hypertension, pre-eclampsia and severe pre-eclampsia. These patients should be referred to the doctor
  • Nutrition – what food to eat and what foods to avoid during pregnancy. Self-care during pregnancy – the importance of hygiene Discuss breastfeeding and benefits during the prenatal consultation. Explain the danger signs and the signs of labor.
  • Diagnosis of pregnancy &antenatal care for undergraduate

    1. 1. Diagnosis of pregnancy DR: MANAL BEHERYZagazig University , Egypt
    2. 2. Principles of diagnosisIn the majority of women, the diagnosis of pregnancy is usually straightforward based on a history of amenorrhea and a positive pregnancy test.women with irregular periods or irregular vaginal bleeding , the diagnosis of pregnancy is more complex. Other symptoms of pregnancy may alert the clinician to the possibility of pregnancy.
    3. 3. Symptoms of pregnancy:Amenorrhoea: HOWEVERPregnancy may occur during period of lactation amenorrhea.Slight bleeding early in pregnancy (threatened abortion) may be considered by the patient as menses .Hartmans symptoms: slight bleeding occurs at time of menstruation
    4. 4. Symptoms of pregnancy:Morning sickness: nausea, rarely vomiting confined to morningIncreased frequency of micturition.Enlargement of the breast and sensation of heaviness.Easy fatiguability and tendency to sleep.Emotional changes e.g. change of the appetite:
    5. 5. In the second and third trimesters1-Abdominal enlargement2-Quickening -1st perception (sensation) of fetal movements by the lady-PG (18-20 weeks), MP (16-18 weeks)
    6. 6. Signs of pregnancy
    7. 7. Chloasma gravidarumButterfly facepigmentation
    8. 8. Breast signsIncreased pigmentation of the nipple and lry areola.
    9. 9. Appearance of Montgomery tubercle in the areoladilated sebaceous glands
    10. 10. Abdominal stria
    11. 11. Linea nigra
    12. 12. - Abdominal signs Inspection:-
    13. 13. 2- Palpation:
    14. 14. Auscultation: Auscultation of FHS as early as 10-12 weeks by sonicadeAuscultation of FHS as early as 20-24 weeks by Pinard stethoscopeAuscultation of umbilical souffle as early as 20-24 weeks.Auscultation of uterine souffl
    15. 15. Pregnancy tests: Principle:Detection ofHCG in the urine orserum .
    16. 16. 1- Urinary pregnancy test:Classically it becomes +Ve 7- 10 day after 1st missed period Commercial testing kits are available that are sensitive to 25 iu/L in urine.By the time the mother has missed her first menstrual period, her hCG levels are around 100 iu/L.
    17. 17. Serum pregnancy test:Classically it becomes +Ve 5- 7 days before 1 st missed periodA quantitative serum HCG assay level of > 5 iu/L will usually denote a pregnancy.With a normal intrauterine pregnancy, the hCG level doubles approximately every 36-48 hours.
    18. 18. Tran abdominal US
    19. 19. Transvaginal ultrasound ( TVS):
    20. 20. 12 WEEKS GESTATIONCROWN RUMP LENGTH(CRL)
    21. 21. 2ND TRIMESTER
    22. 22. Sure signs of pregnancy:Inspection of fetal parts as early as 20th week. -Inspection of fetal movements as early as 20th week.Palpation of fetal movements as early as 20th week. -Palpation of fetal parts as early as 20th week.
    23. 23. Sure signs of pregnancy-Auscultation of FHS at 10-12 weeks by sonicade Investigations: Visualization of fetal parts by ultrasound
    24. 24. ANTENATAL CARE
    25. 25. DefinitionAntenatal care refers to the care that is given to an expected mother from time of conception is confirmed until the beginning of laborIt is a preventative cost effective service
    26. 26. GOALS1-Ensure mother health.2- Ensure delivery of a healthy infant.3-Anticipate problem4- Diagnose problem early.
    27. 27. Objectives1-Early detection and if possible, prevention ofcomplications of pregnancy.2-Educate women on danger and emergency signs &symptoms.3-Prepare the woman and her family for childbirth4- Give education & counseling onfamily planning
    28. 28. Schedual of antenatal care: Medical check up every four weeks up to 28 weeks gestation, Every 2 weeks until 36 weeks of gestation Every week until delivery An average 7-11 antenatal visits/pregnancy More frequent visits may be required if complications arise.
    29. 29. On first antenatal visit1-First : Confirm pregnancy by pregnancy test or US.2-History3-Physical examination4-investigation
    30. 30. HistoryPersonal historyMenstrual historyObstetrical historyFamily historyMedical and surgical historyHistory of present pregnancy
    31. 31. Menstrual history- Ask about- 1-Last menstrual period (LMP).- 2-Regularity and frequency of menstrual cycle.- 3-Contraception method used .- 4-Calculate expected date of delivery (EDD) as1st day of LMP −3 months +7 days, and change the year.
    32. 32. Obstetric History Gravidity? Parity? abortion, and living children. Weight of infant at birth & length of gestation. Type of delivery, location of birth, and type of anesthesia. Maternal or infant complications.
    33. 33. Medical and surgical history:1-Chronic conditions : as diabetes mellitus, hypertension, and renal disease ,cardiac disease.2-Prior operation: as cesarean section, genital repair, and cervical cerclag.3-Allergies, and medications.4-Accidents involving injury of the bony pelvis
    34. 34. History of present pregnancy History suggesting e.g. Diabetes, hypertension and ante partum hemorrhage. Ask about episodes of fever or chills Ask about pain or burning sensation on urination. Abnormal vaginal discharge, itching at the vulva or if partner has a urinary problem.
    35. 35. Emergency symptomsVaginal bleedingSevere abdominal ,epigastric, or pelvic painSevere headache with visual disturbancePersistent vomitingUnconscious/ConvulsionSevere difficulty in breathingFever, chills , dysureaAbsent fetal movement
    36. 36. Assessment and physical examination
    37. 37. Weight measurementMaternal height and weight measurements to determine body mass index(BMI).Maternal weight should be measured at eachantenatal visit
    38. 38. Check for pallor or anemia.1-Look for palmar pallor.2-Look for conjunctival pallor3-Count respiratory rate in one minute.
    39. 39. Blood pressure measurement Measure BP in sitting position. If diastolic BP is 90 mm Hg or higher repeat measurement after 6 hour rest. If diastolic BP is still 90 mm Hg or higher ask the woman if she has:• Severe headache• Blurred vision• Epigastric pain Check urine for protein.
    40. 40. InvestigationsGet baseline on the first or following the first visit. Hemoglobin, blood type Urine analysis VDRL or RPR to screen for syphilis Hepatitis B surface antigen To detect carrier status or active disease
    41. 41. At each visit
    42. 42. At each visit1-Questions about fetal movement2-Ask for danger signs during this pregnancy3-Ask patient if she has any other concerns
    43. 43. Symphysis Fundal hieght • LMP plus 280 days • Add 7 days, subtract 3 months • MacDonalds Rule (cm = weeks)
    44. 44. At third trimesterDoLeopold’s exam
    45. 45. Provide advice on1.Diet and weight gain2.Medication3.Avoid Radiation exposure4.Self-care during pregnancy5.Minor complaints.6. Family planning Breastfeeding7.Birth place preparation and anticipation of complication& Emergency situations.
    46. 46. Diet in pregnancy: Total caloric intake increase to 300 kcal /day due to  15% increase in BMR .Diet show contain 20%Protein(better from animal  source), 30% fat ,and 50% carbohydrates .Sufficient fluids should be available.
    47. 47. Supplementation1-Folic acid 0.4 mg tab daily 2- iron (ferrous sulphate or gluconate )300 mg/daily 3- Ca 1200mg /daily 4-• -Those with a normal balanced diet • probably don’t need extra vitamins
    48. 48. Weight gain in pregnancy:There is a slight loss of pounds during early  pregnancy if the patient experiences much nausea  and vomiting. Weight gain of 2 to 4 lbs(0,5-1 kg) by the end of the  first trimester. Gain of 1 lb(0.5)/ per wk is expected during the  second and third trimesters. Monitoring of weight gain should be done in  conjunction with close monitoring of BP. 
    49. 49. Medications During Pregnancy • Antibiotics - some OK, some not • Local anesthetics - OK • Local with epinephrine - not OK • Aspirin - not OK • Immunizations - some are OK,  some are not • Antimalarial - some OK, some are  not • Narcotics - OK except for addiction  issue
    50. 50. Case Study 
    51. 51. Case Study A 35-year-old G2 P1+0 woman is seen for her first  prenatal visit. Based on her LMP, she is at 15 weeks’ gestation. She has no complaints, and no significant medical  history. She denies dysuria or urinary urgency.Her surgical history is remarkableHer last delivery was a vaginal delivery and was  uncomplicated
    52. 52.  On examinationHer blood pressure (BP) is 100/65 mm Hgheart rate (HR)90 (bpm), respiratory rate (RR) 12,temperature 98°F (36.6°C), weight 70KG.general physical examination is normal
    53. 53. Abdominal examination Her abdomen is non tender Fundal height is at the level ofthe umbilicus. Fetal heart tones are 140 bpm. Her extremities are without edema.
    54. 54. Prenatal laboratoriesCBC: Hgb 10.0 g/dL ,Plt 150,000 WBC 8,000Rubella: nonimmune Hepatitis B surface antigen: positiveBlood type: O, Rh negative UC&S: 10,000 cfu/mL of group BstreptococcusGonorrhea assay: negative Chlamydia assay:  negative
    55. 55. Questions➤ What items should be listed on the problems list?➤ What is your next step for the problems listed?➤ What other testing should be recommended to the  patient?
    56. 56. Problem List:Advanced maternal age 35 Y or greater at EDDfundal height at umbilicus corresponds to 20 weeks) Mild microcytic anemia (Hgb < 10.5) Hepatitis B surface antigen (HBsAg) positive Rh-negative blood type Urine culture with GBS 10,000 cfu/mL,Rubella nonimmune
    57. 57. Next Steps:1. AMA—genetic counseling2. Size/dates—fetal ultrasound to assess GA,  multiple gestation3. Anemia—therapeutic trial of iron4. HBsAg positive—check liver function tests, and  hepatitis B serology toassess for active hepatitis  versus chronic carrier status
    58. 58. Next step5. Rh negative Rhogam at 28 weeks and at delivery if  the baby proves to be Rh positive6. Urine culture with GBS—treat with ampicillin and  re-culture urine, peni-cillin IV prophylaxis in labor7. Rubella status—vaccinate postpartum
    59. 59. Other tests recommended to patientconsider early diabetic screen
    60. 60. Thank you 

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